Fatty liver disease treatment using glucocorticoid and mineralocorticoid receptor antagonists

ABSTRACT

The present invention provides treatment of fatty liver disease using a class of pyrimidinedione cyclohexyl compounds.

CROSS-REFERENCES TO RELATED APPLICATIONS

This application is a Continuation of U.S. patent application Ser. No.14/883,369, filed Oct. 14, 2015, which claims priority to U.S.Provisional Patent Application No. 62/092,041, filed on Dec. 15, 2014,and U.S. Provisional Patent Application No. 62/064,358, filed on Oct.15, 2014, each of which is incorporated in its entirety herein for allpurposes.

BACKGROUND OF THE INVENTION

Liver disorders can be categorized in different groups of diseases, suchas alcohol-induced fatty liver disease (AFLD), nonalcoholic fatty liverdisease (NAFLD), drug- or alcohol-related liver diseases, viraldiseases, immune-mediated liver diseases, metabolic liver diseases, andcomplications associated with hepatic insufficiency and/or livertransplantation. Nonalcoholic fatty liver disease is a common hepaticdisorder with histological features similar to those of alcohol-inducedfatty liver disease, in individuals who consume little or no alcohol.Fatty liver disease is due to an abnormal retention of lipid (fats)within hepatocytes.

Effective treatments for AFLD and NAFLD remain insufficient. To date, notherapeutic drug treatment is established for such patients. There is aneed for novel therapeutic options for managing fatty liver disease.

In most species, including man, the physiological glucocorticoid iscortisol (hydrocortisone). Glucocorticoids are secreted in response toACTH (corticotropin), which shows both circadian rhythm variation andelevations in response to stress and food. Cortisol levels areresponsive within minutes to many physical and psychological stresses,including trauma, surgery, exercise, anxiety and depression. Cortisol isa steroid and acts by binding to an intracellular, glucocorticoidreceptor (GR). In man, glucocorticoid receptors are present in twoforms: a ligand-binding GR-alpha of 777 amino acids; and, a GR-betaisoform which lacks the 50 carboxy terminal residues. Since theseinclude the ligand binding domain, GR-beta is unable to bind the naturalligand, and is constitutively localized in the nucleus. The GR is alsoknown as the GR II.

Cortisol and other glucocorticoids can also act on the mineralocorticoidreceptor (MR), in which case they are referred to as mineralocorticoidsor mineralocorticoid recepter antagonists (MRAs). The mineralocorticoidreceptor primarily regulates the salt concentration in the body. The MRcan have substantially equal affinity for mineralocorticoids andglucocorticoids.

The biologic effects of cortisol, including those caused byhypercortisolemia, can be modulated at the GR level using receptormodulators, such as agonists, partial agonists and antagonists. Severaldifferent classes of agents are able to block the physiologic effects ofGR-agonist binding. These antagonists include compositions which, bybinding to GR, block the ability of an agonist to effectively bind toand/or activate the GR. One such known GR antagonist, mifepristone, hasbeen found to be an effective anti-glucocorticoid agent in humans(Bertagna (1984) J. Clin. Endocrinol. Metab. 59:25). Mifepristone bindsto the GR with high affinity, with a dissociation constant (K_(d)) of10⁻⁹ M (Cadepond (1997) Annu. Rev. Med. 48:129).

In addition to cortisol, the biological effects of other steroids can bemodulated at the GR level using receptor modulators, such as agonists,partial agonists and antagonists. When administered to subjects in needthereof, steroids can provide both intended therapeutic effects, e.g.,by stimulating glucocorticoid receptor transrepression, as well asnegative side effects, e.g. by chronic glucocorticoid receptortransactivation.

What is needed in the art are new compositions and methods formodulating GR receptors to treat fatty liver disease. Surprisingly, thepresent invention meets these and other needs.

BRIEF SUMMARY OF THE INVENTION

In one embodiment, the present invention provides a method of treatingfatty liver disease. The method includes administering to a subject inneed thereof, a therapeutically effective amount of a compound ofFormula I, thereby treating the fatty liver disease, wherein thecompound of Formula I has the structure:

In the compound of Formula I, the dashed line is absent or a bond. X isO or S. R¹ is cycloalkyl, heterocycloalkyl, aryl or heteroaryl,optionally substituted with from 1 to 3 R^(1a) groups. Each R^(1a) isindependently H, C₁₋₆ alkyl, C₂₋₆ alkenyl, C₂₋₆ alkynyl, C₁₋₆ alkoxy,C₁₋₆ alkyl-OR^(1b), halogen, C₁₋₆ haloalkyl, C₁₋₆ haloaloxy,—NR^(1b)R^(1c), —C(O)R_(1b), —C(O)OR^(1b), —OC(O)R^(1b), —OC(O)R^(1b),—C(O)NR^(1b)R^(1c), —NR^(1b)(O)R^(1c), —SO₂R^(1b), —SO₂NR^(1b)R^(1C),cycloalkyl, heterocycloalkyl, aryl or heteroaryl. R^(1b) and R^(1c) areeach H or C₁₋₆ alkyl. R² is H, C₁₋₆ alkyl, C₁₋₆ alkyl-OR^(1b), C₁₋₆alkyl-NR^(1b)R^(1c) or C₁₋₆ alkylene-heterocycloalkyl. R³ is H or C₁₋₆alkyl. Ar is aryl, optionally substituted with 1-4 R⁴ groups. Each R⁴ isH, C₁₋₆ alkyl, C₁₋₆ alkoxy, halogen, C₁₋₆ haloalkyl or C₁₋₆ haloalkoxy.L¹ is a bond or C₁₋₆ alkylene. Subscript n is an integer from 0 to 3.Also included are the salts and isomers of the compounds recited herein.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the percentage of fat (lipid droplets) in Oil Red O stainedlivers from mice that received a high fat diet and Compound 1 (60mg/kg/day) relative to control mice that received a high fat diet andvehicle.

FIGS. 2A and 2B show Oil Red O staining of lipid droplets from liversfrom a mouse that received a high fat (“HF”) diet and Compound 1 (FIG.2A) and a control mouse that received a high fat diet and vehicle (FIG.2B).

FIG. 3 shows the percentage of fat (lipid droplets) in Oil Red O stainedlivers from mice that received a high fat diet and either mifepristoneor Compound 1 (60 mg/kg/day) relative to control mice that received ahigh fat diet and vehicle. *p<0.05 “Compound 1” compared to “CTRL”

FIG. 4 shows triglyceride levels in livers of mice given a normal diet(the “CHOW” group), mice given a high fat diet for 3 weeks (the“HF-3wks” group), mice given a high fat diet for 6 weeks (the “HF-6wks”group), mice given a high fat diet and Compound 1 for 6 weeks (the“HF+118335-6wks” group), and mice given a high fat diet for 6 weeks withadministration of Compound 1 only for the last 3 weeks (the “HF-118335rev” group). **p<0.01 compared to “CHOW”; #p<0.05 compared to “HF-6wks”;##p<0.01 compared to “HF-6wks”.

DETAILED DESCRIPTION OF THE INVENTION I. General

The present invention provides compounds and methods for the treatmentof fatty liver disease by administering a compound of the presentinvention to a patient suffering from a fatty liver disease. Withoutbeing bound by any theory, contrary to the accepted understanding in theart that the compounds of the present invention bind specifically to theglucocorticoid receptor, treatment of fatty liver disease in the presentinvention is accomplished by binding to both the glucorticoid andmineralocorticoid receptors, rather than binding specifically to theglucocorticoid receptor over other nuclear receptors such as themineralocorticoid receptor and the progesterone receptor.

II. Definitions

The abbreviations used herein have their conventional meaning within thechemical and biological arts.

Where substituent groups are specified by their conventional chemicalformulae, written from left to right, they equally encompass thechemically identical substituents that would result from writing thestructure from right to left, e.g., —CH₂O— is equivalent to —OCH₂—.

“Alkyl” refers to a straight or branched, saturated, aliphatic radicalhaving the number of carbon atoms indicated. For example, C₁-C₆ alkylincludes, but is not limited to, methyl, ethyl, propyl, butyl, pentyl,hexyl, iso-propyl, iso-butyl, sec-butyl, tert-butyl, etc.

“Alkylene” refers to either a straight chain or branched alkylene of 1to 7 carbon atoms, i.e. a divalent hydrocarbon radical of 1 to 7 carbonatoms; for instance, straight chain alkylene being the bivalent radicalof Formula —(CH₂)_(n)—, where n is 1, 2, 3, 4, 5, 6 or 7. Preferablyalkylene represents straight chain alkylene of 1 to 4 carbon atoms, e.g.a methylene, ethylene, propylene or butylene chain, or the methylene,ethylene, propylene or butylene chain mono-substituted by C₁-C₃-alkyl(preferably methyl) or disubstituted on the same or different carbonatoms by C₁-C₃-alkyl (preferably methyl), the total number of carbonatoms being up to and including 7. One of skill in the art willappreciate that a single carbon of the alkylene can be divalent, such asin —CH((CH₂)_(n)CH₃)—, wherein n=0-5.

“Alkenyl” refers to either a straight chain or branched hydrocarbon of 2to 6 carbon atoms, having at least one double bond. Examples of alkenylgroups include, but are not limited to, vinyl, propenyl, isopropenyl,1-butenyl, 2-butenyl, isobutenyl, butadienyl, 1-pentenyl, 2-pentenyl,isopentenyl, 1,3-pentadienyl, 1,4-pentadienyl, 1-hexenyl, 2-hexenyl,3-hexenyl, 1,3-hexadienyl, 1,4-hexadienyl, 1,5-hexadienyl,2,4-hexadienyl, or 1,3,5-hexatrienyl. Alkenyl groups can also have from2 to 3, 2 to 4, 2 to 5, 3 to 4, 3 to 5, 3 to 6, 4 to 5, 4 to 6 and 5 to6 carbons. The alkenyl groups is typically monovalent, but can bedivalent, such as when the alkenyl group links two moieties together.

“Alkynyl” refers to either a straight chain or branched hydrocarbon of 2to 6 carbon atoms, having at least one triple bond. Examples of alkynylgroups include, but are not limited to, acetylenyl, propynyl, 1-butynyl,2-butynyl, isobutynyl, sec-butynyl, butadiynyl, 1-pentynyl, 2-pentynyl,isopentynyl, 1,3-pentadiynyl, 1,4-pentadiynyl, 1-hexynyl, 2-hexynyl,3-hexynyl, 1,3-hexadiynyl, 1,4-hexadiynyl, 1,5-hexadiynyl,2,4-hexadiynyl, or 1,3,5-hexatriynyl. Alkynyl groups can also have from2 to 3, 2 to 4, 2 to 5, 3 to 4, 3 to 5, 3 to 6, 4 to 5, 4 to 6 and 5 to6 carbons. The alkynyl groups is typically monovalent, but can bedivalent, such as when the alkynyl group links two moieties together.

“Alkoxy” refers to an alkyl radical as described above which also bearsan oxygen substituent capable of covalent attachment to anotherhydrocarbon for example, methoxy, ethoxy or t-butoxy group.

“Halogen,” by itself or as part of another substituent, means, unlessotherwise stated, a fluorine, chlorine, bromine, or iodine atom.

“Haloalkyl” refers to alkyl as defined above where some or all of thehydrogen atoms are substituted with halogen atoms. Halogen (halo)preferably represents chloro or fluoro, but may also be bromo or iodo.For example, haloalkyl includes trifluoromethyl, fluoromethyl,1,2,3,4,5-pentafluoro-phenyl, etc. The term “perfluoro” defines acompound or radical which has at least two available hydrogenssubstituted with fluorine. For example, perfluoromethane refers to1,1,1-trifluoromethyl.

“Haloalkoxy” refers to alkoxy as defined above where some or all of thehydrogen atoms are substituted with halogen atoms. “Haloalkoxy” is meantto include monohaloalkyl(oxy) and polyhaloalkyl(oxy).

“Alkylamine” refers to an alkyl groups as defined within, having one ormore amino groups. The amino groups can be primary, secondary ortertiary. The alkyl amine can be further substituted with a hydroxygroup. Alkyl amines useful in the present invention include, but are notlimited to, ethyl amine, propyl amine, isopropyl amine, ethylene diamineand ethanolamine. The amino group can link the alkyl amine to the pointof attachment with the rest of the compound, be at the omega position ofthe alkyl group, or link together at least two carbon atoms of the alkylgroup. One of skill in the art will appreciate that other alkyl aminesare useful in the present invention.

“Cycloalkyl” refers to a saturated or partially unsaturated, monocyclic,fused bicyclic or bridged polycyclic ring assembly containing from 3 to12 ring atoms, or the number of atoms indicated. For example,C₃-C₈cycloalkyl includes cyclopropyl, cyclobutyl, cyclopentyl,cyclohexyl, cycloheptyl, and cyclooctyl. Cycloalkyl also includesnorbornyl and adamantyl.

“Heterocycloalkyl” refers to a ring system having from 3 ring members toabout 20 ring members and from 1 to about 5 heteroatoms such as N, O andS. Additional heteroatoms can also be useful, including, but not limitedto, B, Al, Si and P. The heteroatoms can also be oxidized, such as, butnot limited to, —S(O)— and —S(O)₂—. For example, heterocycle includes,but is not limited to, tetrahydrofuranyl, tetrahydrothiophenyl,morpholino, pyrrolidinyl, pyrrolinyl, imidazolidinyl, imidazolinyl,pyrazolidinyl, pyrazolinyl, piperazinyl, piperidinyl, indolinyl,quinuclidinyl and 1,4-dioxa-8-aza-spiro[4.5]dec-8-yl.

“Alkylene-heterocycloalkyl” refers to a heterocycloalkyl group, asdefined above, which is linked to another group by an alkylene. Theheterocycloalkyl and the group to which the heterocycloalkyl is linkedby an alkylene can be linked to the same atom or different atom of thealkylene.

“Aryl” means, unless otherwise stated, a polyunsaturated, aromatic,hydrocarbon substituent which can be a single ring or multiple rings(preferably from 1 to 3 rings) which are fused together or linkedcovalently. Examples include, but are not limited to, phenyl, biphenyl,naphthyl, and benzyl.

“Heteroaryl” refers to aryl groups (or rings) that contain from one tofour heteroatoms selected from N, O, and S, wherein the nitrogen andsulfur atoms are optionally oxidized, and the nitrogen atom(s) areoptionally quaternized. A heteroaryl group can be attached to theremainder of the molecule through a carbon or heteroatom. Non-limitingexamples of aryl and heteroaryl groups include phenyl, 1-naphthyl,2-naphthyl, 4-biphenyl, 1-pyrrolyl, 2-pyrrolyl, 3-pyrrolyl, 3-pyrazolyl,2-imidazolyl, 4-imidazolyl, pyrazinyl, 2-oxazolyl, 4-oxazolyl,2-phenyl-4-oxazolyl, 5-oxazolyl, 3-isoxazolyl, 4-isoxazolyl,5-isoxazolyl, 2-thiazolyl, 4-thiazolyl, 5-thiazolyl, 2-furyl, 3-furyl,2-thienyl, 3-thienyl, 2-pyridyl, 3-pyridyl, 4-pyridyl, 2-pyrimidyl,4-pyrimidyl, 5-benzothiazolyl, purinyl, 2-benzimidazolyl, 5-indolyl,1-isoquinolyl, 5-isoquinolyl, 2-quinoxalinyl, 5-quinoxalinyl,3-quinolyl, and 6-quinolyl. Substituents for each of the above notedaryl and heteroaryl ring systems are selected from the group ofacceptable substituents described below.

For brevity, the term “aryl” when used in combination with other terms(e.g., aryloxy, arylthioxy, arylalkyl) includes both aryl and heteroarylrings as defined above. Thus, the term “arylalkyl” is meant to includethose radicals in which an aryl group is attached to an alkyl group(e.g., benzyl, phenethyl, pyridylmethyl and the like) including thosealkyl groups in which a carbon atom (e.g., a methylene group) has beenreplaced by, for example, an oxygen atom (e.g., phenoxymethyl,2-pyridyloxymethyl, 3-(1-naphthyloxy)propyl, and the like). Likewise,the term “heteroarylalkyl” is meant to include those radicals in which aheteroaryl group is attached to an alkyl group.

Each of the above terms (e.g., “alkyl,” “aryl” and “heteroaryl”) aremeant to include both substituted and unsubstituted forms of theindicated radical. Examples of substituents for each type of radical areprovided below.

Substituents for the alkyl and heteroalkyl radicals (including thosegroups often referred to as alkylene, alkenyl, heteroalkylene,heteroalkenyl, alkynyl, cycloalkyl, heterocycloalkyl, cycloalkenyl, andheterocycloalkenyl) can be one or more of a variety of groups selectedfrom, but not limited to: —OR′, ═O, ═NR′, ═N—OR′, —NR′R″, —SR′,-halogen, —SiR′R″R″′, —OC(O)R′, —C(O)R′, —CO₂R′, —CONR′R″, 13OC(O)NR′R″, —NR″C(O)R′, —NR′—C(O)NR″R″′, —NR″C(O)₂R′,—NR—C(NR′R″R″′)═NR″″, —NR—C(NR′R″)═NR″′, —S(O)R′, —S(O)₂R′, —S(O)₂NR′R″,—NR(SO₂)R′, —CN and —NO₂ in a number ranging from zero to (2m′+1), wherem′ is the total number of carbon atoms in such radical. R′, R″, R″′ andR″″ each preferably independently refer to hydrogen, substituted orunsubstituted heteroalkyl, substituted or unsubstituted cycloalkyl,substituted or unsubstituted heterocycloalkyl, substituted orunsubstituted aryl (e.g., aryl substituted with 1-3 halogens),substituted or unsubstituted alkyl, alkoxy or thioalkoxy groups, orarylalkyl groups. When a compound of the present invention includes morethan one R group, for example, each of the R groups is independentlyselected as are each R′, R″, R″′ and R″″ groups when more than one ofthese groups is present. When R′ and R″ are attached to the samenitrogen atom, they can be combined with the nitrogen atom to form a 4-,5-, 6-, or 7-membered ring. For example, —NR′R″ is meant to include, butnot be limited to, 1-pyrrolidinyl and 4-morpholinyl. From the abovediscussion of substituents, one of skill in the art will understand thatthe term “alkyl” is meant to include groups including carbon atoms boundto groups other than hydrogen groups, such as haloalkyl (e.g., —CF₃ and—CH₂CF₃) and acyl (e.g., —C(O)CH₃, —C(O)CF₃, —C(O)CH₂OCH₃, and thelike).

Similar to the substituents described for the alkyl radical,substituents for the aryl and heteroaryl groups are varied and areselected from, for example: halogen, —OR′, —NR′R″, —SR′, -halogen,—SiR′R″R″′, —OC(O)R′, —C(O)R′, —CO₂R′, —CONR′R″, —OC(O)NR′R″,—NR″C(O)R′, —NR′—C(O)NR″R″′, —NR″C(O)₂R′, —NR—C(NR′R″R″′)═NR″″,—NR—C(NR′R″)═NR′″, —S(O)R′, —S(O)₂R′, —S(O)₂NR′R″, —NR(SO₂)R′, —CN and—NO₂, —R′, —N₃, —CH(Ph)₂, fluoro(C₁-C₄)alkoxy, and fluoro(C₁-C₄)alkyl,in a number ranging from zero to the total number of open valences onthe aromatic ring system; and where R′, R″, R″′ and R″″ are preferablyindependently selected from hydrogen, substituted or unsubstitutedalkyl, substituted or unsubstituted heteroalkyl, substituted orunsubstituted cycloalkyl, substituted or unsubstituted heterocycloalkyl,substituted or unsubstituted aryl and substituted or unsubstitutedheteroaryl. When a compound of the present invention includes more thanone R group, for example, each of the R groups is independently selectedas are each R′, R″, R″′ and R″″ groups when more than one of thesegroups is present.

Where two substituents are “optionally joined together to form a ring,”the two substituents are covalently bonded together with the atom oratoms to which the two substituents are joined to form a substituted orunsubstituted aryl, a substituted or unsubstituted heteroaryl, asubstituted or unsubstituted cycloalkyl, or a substituted orunsubstituted heterocycloalkyl ring.

“Salt” refers to acid or base salts of the compounds used in the methodsof the present invention. Illustrative examples of pharmaceuticallyacceptable salts are mineral acid (hydrochloric acid, hydrobromic acid,phosphoric acid, and the like) salts, organic acid (acetic acid,propionic acid, glutamic acid, citric acid and the like) salts,quaternary ammonium (methyl iodide, ethyl iodide, and the like) salts.It is understood that the pharmaceutically acceptable salts arenon-toxic. Additional information on suitable pharmaceuticallyacceptable salts can be found in Remington's Pharmaceutical Sciences,17th ed., Mack Publishing Company, Easton, Pa., 1985, which isincorporated herein by reference.

“Hydrate” refers to a compound that is complexed to at least one watermolecule. The compounds of the present invention can be complexed withfrom 1 to 10 water molecules.

“Isomers” refers to compounds with the same chemical formula but whichare structurally distinguishable.

“Tautomer” refers to one of two or more structural isomers which existin equilibrium and which are readily converted from one form to another.

“Pharmaceutically acceptable excipient” and “pharmaceutically acceptablecarrier” refer to a substance that aids the administration of an activeagent to and absorption by a subject and can be included in thecompositions of the present invention without causing a significantadverse toxicological effect on the patient. Non-limiting examples ofpharmaceutically acceptable excipients include water, NaCl, normalsaline solutions, lactated Ringer's, normal sucrose, normal glucose,binders, fillers, disintegrants, lubricants, coatings, sweeteners,flavors and colors, and the like. One of skill in the art will recognizethat other pharmaceutical excipients are useful in the presentinvention.

“Treat”, “treating” and “treatment” refer to any indicia of success inthe treatment or amelioration of an injury, pathology or condition,including any objective or subjective parameter such as abatement;remission; diminishing of symptoms or making the injury, pathology orcondition more tolerable to the patient; slowing in the rate ofdegeneration or decline; making the final point of degeneration lessdebilitating; improving a patient's physical or mental well-being. Thetreatment or amelioration of symptoms can be based on objective orsubjective parameters; including the results of a physical examination,neuropsychiatric exams, and/or a psychiatric evaluation.

“Nuclear receptors” refers to a class of proteins responsible forsensing and responding to steroid and thyroid hormones, as well assynthetic hormones and compounds. There are a number of sub-families,including thyroid hormone receptor-like, retinoid X receptor-like,estrogen receptor-like, and nerve growth factor IB-like, among others.The subfamily estrogen receptor-like includes the families estrogenreceptor, estrogen related receptor, and 3-ketosteroid receptors. The3-ketosteroid receptors family includes numerous receptors such as, butnot limited to, the glucocorticoid receptor (GR), the mineralocorticoidreceptor (MR), the estrogen receptor (ER), the progesterone receptor(PR), and the androgen receptor (AR).

“Glucocorticoid receptor” (“GR”) refers to a family of intracellularreceptors which specifically bind to cortisol and/or cortisol analogs.The glucocorticoid receptor is also referred to as the cortisolreceptor. The term includes isoforms of GR, recombinant GR and mutatedGR. “Glucocorticoid receptor” (“GR”) refers to the type II GR whichspecifically binds to cortisol and/or cortisol analogs such asdexamethasone (See, e.g., Turner & Muller, J Mol Endocrinol Oct. 1, 200535 283-292). Inhibition constants (K_(i)) for the compounds of thepresent invention against the human nuclear receptors are between 0.0001nM to 1,000 nM; preferably between 0.0005 nM to 10 nM, and mostpreferably between 0.001 nM to 1 nM.

“Modulating a nuclear receptor” refers to methods for adjusting theresponse of a glucocorticoid receptor towards glucocorticoids,glucocorticoid antagonists, agonists, and partial agonists, as well as amineralocorticoid receptor towards mineralocorticoids, MR antagonists,agonists and partial agonists. The methods include contacting a GR andMR with an effective amount of either an antagonist, an agonist, or apartial agonist and detecting a change in GR activity, or GR and MRactivity.

“Nuclear receptor modulator” refers to any composition or compound whichmodulates the binding of a glucocorticoid receptor (GR) agonist, such ascortisol, or cortisol analogs, synthetic or natural, to a GR, as well asmodulating the binding of a MR agonist, such as aldosterone, or analogsthereof, to a MR. The modulation can include partially or completelyinhibiting (antagonizing) the binding of a GR agonist to a GR, and/or aMR agonist to a MR.

“Antagonizing” refers to blocking the binding of an agonist at areceptor molecule or to inhibiting the signal produced by areceptor-agonist. A receptor antagonist blocks or dampensagonist-mediated responses.

“Glucocorticoid receptor antagonist” refers to any composition orcompound which partially or completely inhibits (antagonizes) thebinding of a glucocorticoid receptor (GR) agonist, such as cortisol, orcortisol analogs, synthetic or natural, to a GR.

“Specific glucocorticoid receptor antagonist” or “specificmineralocorticoid receptor antagonist” refers to any composition orcompound which inhibits any biological response associated with thebinding of a GR and/or an MR to an agonist. By “specific,” we intend thedrug to preferentially bind to the GR and/or MR rather than othernuclear receptors, such as the estrogen receptor (ER), progesteronereceptor (PR) or the androgen receptor (AR).

“Mineralocorticoid receptor” refers to a family of intracellularreceptors that bind to mineralocorticoids such as aldosterone, andglucocorticoids such as cortisol, with substantially equal affinity. Themineralocorticoid receptor (MR) is also referred to as the aldosteronereceptor or nuclear receptor subfamily 3, group C, member 2, (NR3C2).The MR belongs to the cytosolic receptor family. The MR is activated bymineralocorticoids such as aldosterone and its precursordeoxycorticosterone as well as glucocorticoids, like cortisol.

“Mineralocorticoid receptor antagonist” refers to any composition orcompound which partially or completely inhibits (antagonizes) thebinding of a mineralocorticoid receptor (MR) agonist, such asaldosterone, or aldosterone analogs, synthetic or natural, to a MR.

“Patient” or “subject” refers to a living organism suffering from orprone to a condition that can be treated by administration of apharmaceutical composition as provided herein. Non-limiting examplesinclude humans, other mammals and other non-mammalian animals.

“Therapeutically effective amount” refers to an amount of a conjugatedfunctional agent or of a pharmaceutical composition useful for treatingor ameliorating an identified disease or condition, or for exhibiting adetectable therapeutic or inhibitory effect. The effect can be detectedby any assay method known in the art.

The terms “a,” “an,” or “a(n)”, when used in reference to a group ofsubstituents or “substituent group” herein, mean at least one. Forexample, where a compound is substituted with “an” alkyl or aryl, thecompound is optionally substituted with at least one alkyl and/or atleast one aryl, wherein each alkyl and/or aryl is optionally different.In another example, where a compound is substituted with “a” substituentgroup, the compound is substituted with at least one substituent group,wherein each substituent group is optionally different.

“Fatty liver disease” refers to a disease or a pathological conditioncaused by, at least in part, abnormal hepatic lipid deposits. Fattyliver disease includes, e.g., alcoholic fatty liver disease,nonalcoholic fatty liver disease, and acute fatty liver of pregnancy.Fatty liver disease may be, e.g., macrovesicular steatosis ormicrovesicular steatosis.

“Alcohol-related liver disease” or “ARLD” refers to diseases of theliver that are wholly, or in part, caused by, or attributable to,excessive consumption of alcohol. There are four main types of ARLD,alcoholic fatty liver (AFL, a sub-type of fatty liver disease),alcoholic steatohepatitis (ASH), alcoholic-induced cirrhosis, andalcoholic hepatocellular cancer. As used herein, “excessive consumptionof alcohol” generally refers to the consumption of more than about 15-30g/day of ethanol.

The physiological effects of alcohol consumption on liver function ordisease are dependent on a variety of genetic and non-genetic factorsthat modify both individual susceptibility and the clinical course ofARLD. Thus, in certain patients, ARLD can develop at much lower rates ofalcohol consumption, including consumption of at least about 12 g/day,15 g/day, 20 g/day, 25 g/day or more. Moreover, it is understood that insome patients, estimates of daily consumption of alcohol are an averagevalue that includes periods of heavy alcohol consumption and periods oflittle or no alcohol consumption. Such an average value can include anaverage of alcohol consumption over at least about a week, two weeks, amonth, three months, six months, nine months, a year, 2, 3, or 4 years,or more. In some cases, the determination of whether a liver dysfunctionis an ARLD is based on reference to a variety of factors including, butnot limited to: the amount and type of alcoholic beverage consumption(e.g., beer or spirits); the duration of alcohol abuse; patterns ofdrinking behavior (e.g., binge drinking, drinking without co-consumptionof food, etc.); gender; ethnicity; co-existing disease conditions suchas metabolic syndrome or diabetes, iron overload, or infection withhepatitis virus, genetic markers; family history; liver enzyme levels;proinflammatory cytokine levels; gene or protein expression analysis; orhistopathological examination of liver tissue or cells.

“Liver disorder unrelated to excessive ingestion of alcohol” is a liverdisorder that is distinguished from ARLD. Such a disorder thereforerefers to a wide array of liver diseases that are not caused by alcoholconsumption. For example, hepatitis can be caused by viral infection. Aliver disorder caused by excessive alcohol consumption and otherfactors, is considered an ARLD rather than a liver disorder unrelated toexcessive ingestion of alcohol. In contrast, a liver disorder merelyexacerbated by excessive alcohol consumption is considered a liverdisorder unrelated to excessive ingestion of alcohol.

“Nonalcoholic fatty liver disease” or “NAFLD” refers to a fatty liverdisease characterized by the presence of fat (lipids) in the liver andno substantial inflammation or liver damage. NAFLD can progress intononalcoholic steatohepatitis and then into irreversible, advanced liverscarring or cirrhosis.

“Nonalcoholic steatohepatitis” or “NASH” refers a fatty liver disease,which resembles alcoholic liver disease, but occurs in people who drinklittle or no alcohol. The major feature in NASH is fat in the liver,along with inflammation and damage. NASH can lead to cirrhosis, in whichthe liver is permanently damaged and scarred and is no longer able tofunction properly. A differential diagnosis of NASH versus NAFLD may bedetermined by liver biopsy.

Descriptions of compounds of the present invention are limited byprinciples of chemical bonding known to those skilled in the art.Accordingly, where a group may be substituted by one or more of a numberof substituents, such substitutions are selected so as to comply withprinciples of chemical bonding and to give compounds which are notinherently unstable and/or would be known to one of ordinary skill inthe art as likely to be unstable under ambient conditions, such asaqueous, neutral, or physiological conditions.

III. Fatty Liver Disease

Fatty liver disease (FLD, also known as hepatosteatosis) is a prevalentliver condition that occurs when lipids accumulate in liver cells. Thelipid accumulation causes cellular injury and makes the liversusceptible to further injuries. Fatty liver disease is characterized bythe build-up of excessive fat (lipids) in liver cells, generally causedby abnormal retention of lipids by the liver cells (i.e., steatosis). Inaddition to fat, proteins and water are retained in the hepatocytes,which can lead to a ballooning of hepatocytes. The accumulation of fatin the liver may be attributed to a perturbation of one of the followingsteps in the lipid metabolism of hepatocytes and adipocytes: (1)increased free fatty acid delivery to the liver; (2) increased freefatty acid synthesis within the liver; (3) decreased beta-oxidation offatty acids; and (4) decreased very low-density lipoprotein synthesis orsecretion. (Bacon et al., Gastroenterology, 1994, 107:1103-1109).

FLD may arise from a number of sources, including excessive alcoholconsumption and metabolic disorders, such as those associated withinsulin resistance, obesity, and hypertension. The disease is mostprevalent in individuals who are obese or who have diabetes. In alcoholinduced fatty liver disease (AFL) initially fat accumulates in livercells, but then the disease can progress to alcoholic hepatitis whichcauses the liver to swell and become damaged if the individual continuesto consume alcohol. The individual can also develop alcoholic cirrhosis,or scarring of the liver which in turn can cause liver failure. Heavydrinkers can progress from AFL to alcoholic hepatitis to alcoholiccirrhosis over time.

Nonalcoholic fatty liver disease (NAFLD) is a liver disorder withhistological features of AFL but in individuals who consume little to noalcohol. Like AFL, NAFLD is due to the abnormal retention of fat(lipids) by hepatocytes. Other fatty liver diseases can develop in apatient with other types of liver diseases, such as but not limited to,chronic viral hepatitis C (HCV), chronic viral hepatitis B (HBV),chronic autoimmune hepatitis (AIH), diabetes and Wilson's disease. Fattyliver can also be associated with indications caused by disruptions inlipid metabolism, such as disorders due to drugs, e.g., gastrointestinaldisorders (e.g., intestinal bacterial outgrowth, gastroparesis andirritable bowel syndrome), chemotherapy, gastrointestinal surgeries forobesity, malnutrition and genetic defects in proteins that processlipids.

In some embodiments, the fatty liver disease is alcohol related liverdisease (ARLD) or nonalcoholic fatty liver disease (NAFLD). In someinstances, the alcohol related liver disease is alcohol fatty liverdisease (AFL), alcoholic steatohepatitis (ASH) or alcoholic cirrhosis.In some instances, the nonalcoholic fatty liver disease is nonalcoholicsteatohepatitis (NASH) or nonalcoholic cirrhosis.

A. Alcohol Related Liver Disease (ARLD)

Alcohol-related liver disease (ARLD) describes a family ofalcohol-related, or alcohol-induced, liver pathologies including alcoholinduced fatty liver disease (AFL), alcoholic hepatitis, and alcoholiccirrhosis. Virtually all persons who are chronic and heavy consumers ofalcohol will develop AFL. Additionally, due to the high prevalence ofcomplicating factors such as obesity, diabetes, and metabolic syndromein the general population, many individuals who do not satisfy thecriteria for chronic heavy consumers of alcohol are susceptible todeveloping AFL.

AFL can be diagnosed via ultrasound. Typically, the liver of a patientwith AFL presents as “echogenic,” meaning more dense than usual to theimaging sound waves. In addition, the liver is typically enlarged due tothe swelling and presence of large amounts of fat.

AFL can also be indicated by, and thus diagnosed due to, presentation ofone or more symptoms or risk factors (e.g., obesity, diabetes, drinkingbehavior, etc.). Fatty liver disease can present symptoms such asfatigue, muscle weakness, abdominal discomfort, weight loss, andconfusion. However, fatty liver disease usually does not present overtphysical symptoms. Fatty liver disease can also be accompanied by, orprecede, inflammation of the liver or hepatic fibrosis. Patients withfatty liver disease generally present elevated serum liver enzymelevels. Moreover, the relative levels of several liver enzymes arealtered. AFL generally presents with a serum aspartate aminotransferase(AST) level that is greater than the level of alanine aminotransferase(ALT). This is distinguished from non-alcoholic fatty liver disease, inwhich ALT is higher than AST.

There are four main pathogenic factors for AFL: (1) Increased generationof NADH caused by alcohol oxidation, favoring fatty acid andtri-glyceride synthesis, and inhibiting mitochondrial β-oxidation offatty acids. (2) Enhanced hepatic influx of free fatty acids fromadipose tissue and of chylomicrons from the intestinal mucosa. (3)Ethanol-mediated inhibition of adenosine monophosphate activated kinase(AMPK) activity resulting in increased lipogenesis and decreasedlipolysis by inhibiting peroxisome proliferating-activated receptor α(PPARα) and stimulating sterol regulatory element binding protein 1 c(SREBP1c). And, (4) Damage to mitochondria and microtubules byacetaldehyde, which results in a reduction of NADH oxidation and theaccumulation of VLDL, respectively.

Successful treatment of AFL is indicated by improvement of one or moreclinical, laboratory, or histopathological symptoms. For example,successful treatment can be indicated by a reduction in volume of fattyliver, e.g., as exhibited by ultrasound examination. As another example,successful treatment can be indicated by a reduction of one or moreclinical symptoms such as fatigue, weakness, or cessation of weightloss. As another example, successful treatment can be indicated by anormalization of liver enzyme levels or relative levels (e.g.,normalization of the aspartate aminotransferase/alanine aminotransferaseratio).

Alcoholic hepatitis, or alcoholic steatohepatitis (ASH), is the nextstage of ARLD after AFL. As such, AFL is a pre-requisite for developmentof ASH. Seventeen percent of all liver biopsies of patients who areadmitted for alcohol detoxification reveal ASH and 40% of patients withalcoholic cirrhosis also have ASH in a cirrhotic liver. Twenty-fivepercent of patients develop excessive liver necrosis with clinical signsof hepatic failure and hepatic encephalopathy. In severe cases ASH maycause profound liver damage, increased resistance to blood flow and isassociated with a poor prognosis. Acute mortality of severe ASH isbetween about 15% and 25%. ASH is characterized by an inflammation ofthe liver. Various factors may contribute to the development of ASH,including: (1) acetaldehyde-induced toxic effects; (2) reactive oxygenspecies (ROS) generation and the resulting lipid peroxidation; (3)upregulation of proinflammatory cytokines; and (4) impairedubiquitin-proteasome pathway function.

Acetaldehyde binds to proteins and to DNA resulting in functionalalterations and protein adducts. Such adducts can activate the immunesystem by forming autoantigens. Acetaldehyde also induces mitochondriadamage and impairs glutathione function, leading to oxidative stress andapoptosis.

The main sources of ROS are CYP2E1-dependent mitochondrial electrontransport, NADH-dependent cytochrome reductase, and xanthine oxidase.Chronic alcohol intake markedly up-regulates CYP2E1, which exacerbatesROS generation. Moreover, CYP2E1 metabolizes ethanol to acetaldehyderesulting in further alteration of protein and DNA.

Alcohol metabolites and ROS stimulate signaling pathways such as thosemediated by NF-κB, STAT-JAK, and JNK in hepatic resident cells, leadingto the local synthesis of inflammatory mediators such as TNFα and CXCchemokines (e.g., interleukin-8), as well as osteopontin. Alcohol abusealso results in changes in the colonic microbiota and increasedintestinal permeability, leading to elevated serum levels oflipopolysaccharides that induce inflammatory actions in Kupffer cellsvia CD14/TLR4. The resulting inflammatory milieu in the alcoholic liverleads to polymorphonuclear leukocyte (PMN) infiltration, ROS formationand hepatocellular damage.

ASH histopathology can be characterized by ballooning degeneration ofhepatocytes associated with necrosis, enhanced apoptosis, andfrequently, the occurrence of Mallory Denk bodies (MDBs). ASHhistopathology can also exhibit infiltration of immune cells, includingpolymorphonuclear cells, T-lymphocytes, or natural killer cells. MDBsare associated with poor prognosis. In addition to MDB, giantmitochondria can be observed in the liver cells of patients with ASH.Additional histopathological characteristics of ASH includemacrovesicular steatosis, microvesicular steatosis, lobular hepatitis,nuclear vacuoles, ductular proliferation, perivencular fibrosis, andfibrosis or cirrhosis.

Patients with ASH may develop progressive fibrosis. In ARLD, thefibrotic tissue is typically located in pericentral and perisinusoidalareas. In advanced stages, collagen bands are evident and bridgingfibrosis develops. This condition precedes the development ofregeneration nodules and liver cirrhosis. The cellular and molecularmechanisms of fibrosis in ARLD are not completely understood. Alcoholmetabolites such as acetaldehyde can directly activate hepatic stellatecells (HSC), the main collagen-producing cells in the injured liver. HSCcan also be activated paracrinally by damaged hepatocytes, activatedKupffer cells and infiltrating PMN cells. These cells release fibrogenicmediators such as growth factors (TGF-β1, PDGF), cytokines (leptin,angiotensin II, interleukin-8, and TNFα), soluble mediators (nitricoxide), and ROS. Importantly, ROS stimulate pro-fibrogenic intracellularsignaling pathways in HSC including those mediated by ERK, PI3K/AKT, andJNK. They also up-regulate TIMP-1 and decrease the actions ofmetalloproteinases, thereby promoting collagen accumulation. Cells otherthan HSC can also synthesize collagen in ARLD. They include portalfibroblasts and bone-marrow derived cells.

ASH can be classified into mild, moderate, and severe forms due to theintensity and frequency of a wide variety of subjective and objectiveclinical findings. Clinical symptoms of ASH include: nonspecific upperright quadrant pain, nausea, and emesis, frequently accompanied by feverand jaundice. Other symptoms include: fatigue, dry mouth and increasedthirst, or bleeding from enlarged veins in the walls of the lower partof the esophagus. Other skin conditions indicative of ASH include: smallred spider-like veins on the skin, very dark or pale skin, redness onthe feet or hands, or itching. Patients with ASH may also present withsymptoms of alcohol withdrawal and signs of malnutrition. Furtherclinical markers include hepatomegaly, ascites, anorexia,encephalopathy, splenomegaly, weight loss, pancreatitis, orgastrointestinal bleeding. In severe cases, patients can exhibitproblems with thinking, memory, and mood, fainting or lightheadedness,or numbness in legs and feet.

Serum and blood markers of ASH include an increase in the activity ofaspartate aminotransferase and alanine aminotransferase, accompanied bya higher level of aspartate aminotransferase over alanineaminotransferase. Typically, gamma glutamyl peptidase is also elevatedin ASH patients. Elevated gamma glutamyl peptidase is generallyconsidered due to enzyme induction by ethanol; however, aspartateaminotransferase and alanine aminotransferase levels are considered tobe markers of liver cell damage. 40-80% of patients also present withelevated alkaline phosphatase activity levels. In severe ASH, beta andgamma globulin levels are elevated. In addition, ASH can present withelevated leukocyte count with toxic granulation and fever. Hematologicabnormalities for ASH include macrocytotic hyperchromic anemia andthrombocytosis. Severe ASH can also exhibit reduction in parametersindicative of primary liver function such as prothrombin time, serumbilirubin, or serum albumin. In some cases, ASH can be detected by thepresence of urine bilirubin.

ASH is generally indistinguishable from AFL via ultrasound. Howeverultrasound can be useful to exclude extrahepatic cholestasis, which canpresent similar clinical symptoms (e.g., jaundice). If diagnosis cannotbe established by examination of clinical markers, serum or bloodmarkers, and ultrasound, a liver biopsy may be performed. Liver biopsycan also be helpful to determine the severity of the disease or to guidepharmacological intervention.

Successful treatment of ASH is indicated by improvement of one or moreclinical, laboratory, or histopathological symptoms. For example,successful treatment can be indicated by a reduction in volume of fattyliver, e.g., as exhibited by ultrasound examination. As another example,successful treatment can be indicated by a reduction of one or moreclinical symptoms such as fatigue, weakness, or cessation of weightloss. As another example, successful treatment can be indicated by anormalization of liver enzyme levels or relative levels (e.g.,normalization of the aspartate aminotransferase/alanine aminotransferaseratio). As yet another example, successful treatment can be indicated bya reduction in beta and gamma globulin levels or alkaline phosphataselevels. As another example, restoration or improvement of parameters ofprimary liver function such as prothrombin time, serum or urinebilirubin, and serum albumin can indicate successful treatment. As yetone more example, successful treatment can be indicated by amelioration,or cessation, of one or more of hepatomegaly, ascites, anorexia,encephalopathy, splenomegaly, weight loss, pancreatitis, orgastrointestinal bleeding.

Alcoholic cirrhosis is a late stage of serious liver disease marked byinflammation, swelling, fibrosis, damaged cellular membranes, scarring,and necrosis. Between about 10% to about 20% of heavy drinkers willdevelop cirrhosis of the liver. Symptoms of cirrhosis include, but arenot limited to, jaundice, liver enlargement, and pain and tenderness.Successful treatment can be indicated by any reduction in the rate ofprogression of liver function deterioration.

B. Non-Alcoholic Fatty Liver Disease (NAFLD)

NAFLD includes a spectrum of histological forms including hepaticsteatosis, and non-alcoholic steatohepatitis (NASH), which ischaracterized by liver inflammation, steatosis, necrosis and fibrosisdue to the disruption of liver cells. Conditions associated with NAFLDare varied, and include type 2 diabetes, obesity, dyslipidemia,metabolic syndrome, treatment with hepatotoxic drugs, toxins, infectiousagents, or other exogenous causes. For instance, NAFLD may result frommetabolic disorders such as, e.g., galactosemia, glycogen storagediseases, homocystinuria, and tyrosemia, as well as dietary conditionssuch as malnutrition, total parenteral nutrition, starvation, andovernutrition. In certain cases, NAFLD is associated with jejunal bypasssurgery. Other causes include exposure to certain chemicals such as,e.g., hydrocarbon solvents, and certain medications, such as, e.g.,amiodarone, estrogens (e.g., synthetic estrogens), tamoxifen, maleate,methotrexate, nucleoside analogs, and perhexiline. Acute fatty liverconditions can also arise during pregnancy.

NAFLD typically follows a benign, non-progressive clinical course,however, NASH is a potentially serious condition. As many as 25% of NASHpatients may progress to advanced fibrosis, cirrhosis and experiencecomplications of portal hypertension, liver failure and hepatocellularcarcinoma (Yeh and Brunt, Am J Clin Pathol, 2007, 128(5):837-47).

Individuals with NAFLD may be asymptomatic but clinical lab tests canshow elevated liver enzyme levels. Individuals may exhibit symptoms ofNAFLD, such as abdominal discomfort (e.g., discomfort in the right upperabdominal quadrant), acanthosis nigricans, bowel dismotility, coma,constipation, disseminated intravascular coagulopathy, epigastric pain,fatigue, malaise, hepatomegaly (generally with a smooth, firm surfaceupon palpation), hypoglycemia, jaundice, lipomatosis, lipoatrophy,lipodystrophy, nausea, neurological defects, Palmer erythema,panniculitis, periumbilical pain, small bowel bacterial overgrowth,spider angiomata, splenomegaly, subacute liver failure, and vomiting.Clinical evaluation to rule out alcohol related fatty liver disease mayinclude determining if the individual consumes excess alcohol (e.g., >60g/day for men and >20 g/day for women within the past 5 years. Thepresence or level of anti-hepatitis C antibody and serum ceruloplasminlevels can be used to indicate that the individual has NAFLD.

Non-invasive evaluation of biochemistry and metabolism can used todiagnose NAFLD and NASH. By using a biological sample such as blood,plasma or serum, high level of enzymes such as alanine aminotransferase(ALT), aspartate aminotransfersase (AST), alkaline Phosphatase (AP),and/or γ glutamyl transpeptidase (GGT), as well as the presence of otherproteins of liver origin (including haptoglobin, total bilirubin,alpha-2-microglobulin, resistin, cleaved or intact cytokeratin-18) arecommonly measured in addition to serum glucose and insulin resistanceparameters. Since the level of ALT activity is frequently increased inNASH patients (Angulo and Lindor, Best Pract Res Clin Gastroenterol,2002, 16(5):797-810), this criteria is considered as a surrogate markerfor assessing liver injury.

In an individual suspected of having NAFLD or NASH, baseline testing ofserum may include measuring or determining levels of AST, ALT, total anddirect bilirubin, and fasting serum glucose, as well as a lipid panel.For example, steatosis may be indicated by elevated serum levels (oftenmoderately elevated, e.g., elevated approximately 2, 3, 4, 5, 6, 7, 9,10, 11, or 12-fold above normal levels) of liver enzymes (such as, e.g.,AST, ALT, GGT and alkaline phosphatase) when other causes (such as,e.g., acute hepatitis, autoimmune disease, chronic hepatitis, cirrhosis,fulminant hepatitis, hepatocellular carcinoma, metastatic carcinoma,right heart failure, and viral hepatitis) have been eliminated. Forexample, ALT values greater than 32, 24, or 56 units per liter of serumor at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, or more times normalvalues may be indicative of a disorder associated with hepatic lipiddeposits, or by AST values greater than 40 units per liter of serum orat least 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, or more times normalvalues. Mild to moderate elevation of serum aminotransferase levels ismost commonly found (mean range, 100-200 IU/L). The ratio of AST/ALT isoften less than one in NAFLD, but may be greater than one in patientswith alcoholic liver disease or advanced liver disease or if the patientadvances to fibrosis. GGT levels may also be significantly elevated,e.g., at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, or more times normalvalues as defined by a normal, healthy individual. Liver enzyme levelscan be normal in a large percentage of patients with NAFLD, thus normalAST or ALT levels do not exclude the presence of advanced disease. Serumalkaline phosphatase and GGT levels may be mildly abnormal. Given thatmore than 80% of patients with NAFLD have some components of metabolicsyndrome, serum levels of fasting cholesterol and triglycerides, as wellas fasting glucose and insulin, may be determined. Albumin, bilirubin,and platelet levels may be normal unless the disease has evolved tocirrhosis. Some patients with NAFLD have low titers of autoimmuneantibodies (e.g., antinuclear and anti-smooth muscle antiboyy) and anelevation of ferritin (Carey et al., “Nonalcoholic Fatty Liver Disease”in Current Clinical Medicine, 2nd edition, Elsevier, New York. In someembodiments, an AST/ALT ratio of greater than 1 can predict moreadvanced fatty liver disease.

Radiologic methods such as, but not limited to, x-ray imaging,ultrasonography, computed tomography (CT), magnetic resonance imaging(MRI), and magnetic resonance spectroscopy can be used to detect NAFLD.With ultrasonography, increased echogenicity of the liver compared tothe kidneys can indicate liver steatosis.

NASH can be diagnosed using histopathological methods on liver samples(e.g., biopsies) to assess macrovesicular steatosis, ballooningdegeneration, hepatocyte necrosis, lobular inflammation,megamitochondria, infiltration of inflammatory cells, apoptosis, andfibrosis (see, e.g., Brunt and Tiniakos, World J Gastroenterol, 2010,16(42):5286-8296). Hepatocytic ballooning is characterized by swellingand enlargement of the cells, and sometimes the appearance ofcytoplasmic alterations containing Mallory-Denk bodies. Fibrosis canalso develop over time, initially as pericellular/pervenular fibrosisand eventually to portal-central bridging fibrosis and cirrhosis.

Hematoxylin and eosin (H&E), Masson trichrome, Oil Red O andimmunohistochemical staining and other standard histological methodsknown to those of ordinary skill in the art can be performed to analyzetissue and cellular features. A scoring system (e.g., a NAFLD activityscore) that includes one or more histological features can be used toscore and diagnose NAFLD, including NASH. In some embodiments, the NASHClinical Research Network Scoring System developed by the PathologyCommittee of the NASH Clinical Research Network (see, e.g., Kleiner etal., Hepatology, 2005, 41(6): 1313-1321) can be used predict whether anindividual has NAFLD or NASH. The Practice Guidelines published by theAmerican Gastroenterological Association, American Association for theStudy of Liver Diseases, and American College of Gastroenterology(Chalasani et al., Gastroenterology, 2012, 142: 1592-1609) can befollowed by a clinician to diagnose or monitor NAFLD, includingnon-alcoholic fatty liver, NASH and NASH associated cirrhosis.

An individual's liver may be considered to be steatotic when a biopsyreveals at least 5-10% w/w fatty deposits (See, e.g., Clark et al., J.Am. Med. Assoc., 2003, 289:3000-3004 (2003) and Adams et al., Can. Med.Assoc. J., 2005, 172:899-905). A liver with fatty deposits comprising upto 25% (w/w) may be considered mildly steatotic, and a liver with fattydeposits comprising greater than 25% (w/w) may be considered severelysteatotic.

Treatments for NAFLD including NASH include exercise, weight loss andavoiding hepatotoxins or any substance that may damage the liver. Insome embodiments, therapies include administration of antioxidants,cytoprotective agents, antidiabetic agents, insulin-sensitizing agents(e.g. metformin), anti-hyperlipidemic agents, other chemical compounds,such as fibrates, thiazolidinediones (i.e., rosiglitazone orpioglitazone), biguanidies, statins, cannabinoids, and other therapeuticcompounds or molecules that target nuclear receptors, angiotensinreceptors, cannabinoid receptors or HMG-CoA reductase.

Efficacy of treatment may be determined by detecting a reduction in oneor more symptoms or clinical manifestations of a disease as well as anyof the tests described above for diagnosis.

IV. Compounds

In some embodiments, the present invention provides a compound offormula I:

wherein the dashed line is absent or a bond. X is O or S. R¹ iscycloalkyl, heterocycloalkyl, aryl or heteroaryl, optionally substitutedwith from 1 to 3 R^(1a) groups. Each R^(1a) is independently H, C₁₋₆alkyl, C₂₋₆ alkenyl, C₂₋₆ alkynyl, C₁₋₆ alkoxy, C₁₋₆ alkyl-OR^(1b),halogen, C₁₋₆ haloalkyl, C₁₋₆ haloaloxy, —OR^(1b), —NR—C(O)R^(1b),—C(O)OR^(1b), —OC(O)R^(1b), —C(O)NR^(1b)R^(1c), —NR^(1b)C(O)R^(1c),—SO₂R^(1b), —SO₂NR^(1b)R^(1c), cycloalkyl, heterocycloalkyl, aryl orheteroaryl. R^(1b) and R^(1c) are each H or C₁₋₆ alkyl. R² is H, C₁₋₆alkyl, C₁₋₆ alkyl-OR^(1b), C₁₋₆ alkyl-NR^(1b)R^(1c) or C₁₋₆alkylene-heterocycloalkyl. R³ is H or C₁₋₆ alkyl. Ar is aryl, optionallysubstituted with 1-4 R⁴ groups. Each R⁴ is H, C₁₋₆ alkyl, C₁₋₆ alkoxy,halogen, C₁₋₆ haloalkyl or C₁₋₆ haloalkoxy. L¹ is a bond or C¹⁻⁶alkylene. Subscript n is an integer from 0 to 3. Also included are thesalts and isomers of the compounds recited herein.

In some other embodiments, the present invention provides a compoundhaving formula Ia:

In some embodiments, L¹ is methylene. In other embodiments, Ar isphenyl.

In some embodiments, the present invention provides a compound havingformula Ib:

In some other embodiments, the present invention provides a compoundhaving formula Ic:

In some other embodiments, the present invention provides a compoundhaving formula Id:

In some embodiments, each R^(1a), R² and R⁴ are as defined above forFormula I. In some embodiments, the compounds of Formula Id are thosewhere each R^(1a) is independently H, C₁₋₆ alkyl, halogen, or C₁₋₆haloalkyl; R² is H, or C₁₋₆ alkyl; and each R⁴ is H, C₁₋₆ alkyl,halogen, or C₁₋₆ haloalkyl.

In some embodiments, the present invention provides a compound whereinR¹ is aryl or heteroaryl. In other embodiments, R¹ is selected from thegroup consisting of phenyl, pyridyl, pyrimidine, and thiazole. In someother embodiments, each R^(1a) is independently H, C₁₋₆ alkyl, C₁₋₆alkoxy, halogen, C₁₋₆ haloalkyl, —NR^(1b)R^(1c), or —SO₂R^(1b). In stillother embodiments, each R^(1a) is C₁₋₆ haloalkyl. In some otherembodiments, each R^(1a) is independently H, Me, Et, —OMe, F, Cl, —CF₃,—NMe₂, or —SO₂Me. In some embodiments, each R^(1a) is independently H,Me, Et, F, Cl, or —CF₃. In other embodiments, each R^(1a) is —CF₃. Insome other embodiments, R² is H or C₁₋₆ alkyl. In other embodiments, R²is H.

In some embodiments, the present invention provides a compound selectedfrom the following:

In some embodiments, the compound is

In some other embodiments, the present invention provides a compoundhaving the formula:

The compounds of the present invention may exist as salts. The presentinvention includes such salts. Examples of applicable salt forms includehydrochlorides, hydrobromides, sulfates, methanesulfonates, nitrates,maleates, acetates, citrates, fumarates, tartrates (eg (+)-tartrates,(−)-tartrates or mixtures thereof including racemic mixtures,succinates, benzoates and salts with amino acids such as glutamic acid.These salts may be prepared by methods known to those skilled in art.Also included are base addition salts such as sodium, potassium,calcium, ammonium, organic amino, or magnesium salt, or a similar salt.When compounds of the present invention contain relatively basicfunctionalities, acid addition salts can be obtained by contacting theneutral form of such compounds with a sufficient amount of the desiredacid, either neat or in a suitable inert solvent. Examples of acceptableacid addition salts include those derived from inorganic acids likehydrochloric, hydrobromic, nitric, carbonic, monohydrogencarbonic,phosphoric, monohydrogenphosphoric, dihydrogenphosphoric, sulfuric,monohydrogensulfuric, hydriodic, or phosphorous acids and the like, aswell as the salts derived organic acids like acetic, propionic,isobutyric, maleic, malonic, benzoic, succinic, suberic, fumaric,lactic, mandelic, phthalic, benzenesulfonic, p-tolylsulfonic, citric,tartaric, methanesulfonic, and the like. Also included are salts ofamino acids such as arginate and the like, and salts of organic acidslike glucuronic or galactunoric acids and the like. Certain specificcompounds of the present invention contain both basic and acidicfunctionalities that allow the compounds to be converted into eitherbase or acid addition salts.

Other salts include acid or base salts of the compounds used in themethods of the present invention. Illustrative examples ofpharmaceutically acceptable salts are mineral acid (hydrochloric acid,hydrobromic acid, phosphoric acid, and the like) salts, organic acid(acetic acid, propionic acid, glutamic acid, citric acid and the like)salts, and quaternary ammonium (methyl iodide, ethyl iodide, and thelike) salts. It is understood that the pharmaceutically acceptable saltsare non-toxic. Additional information on suitable pharmaceuticallyacceptable salts can be found in Remington's Pharmaceutical Sciences,17th ed., Mack Publishing Company, Easton, Pa., 1985, which isincorporated herein by reference.

Pharmaceutically acceptable salts includes salts of the active compoundswhich are prepared with relatively nontoxic acids or bases, depending onthe particular substituents found on the compounds described herein.When compounds of the present invention contain relatively acidicfunctionalities, base addition salts can be obtained by contacting theneutral form of such compounds with a sufficient amount of the desiredbase, either neat or in a suitable inert solvent. Examples ofpharmaceutically acceptable base addition salts include sodium,potassium, calcium, ammonium, organic amino, or magnesium salt, or asimilar salt. When compounds of the present invention contain relativelybasic functionalities, acid addition salts can be obtained by contactingthe neutral form of such compounds with a sufficient amount of thedesired acid, either neat or in a suitable inert solvent. Examples ofpharmaceutically acceptable acid addition salts include those derivedfrom inorganic acids like hydrochloric, hydrobromic, nitric, carbonic,monohydrogencarbonic, phosphoric, monohydrogenphosphoric,dihydrogenphosphoric, sulfuric, monohydrogensulfuric, hydriodic, orphosphorous acids and the like, as well as the salts derived fromrelatively nontoxic organic acids like acetic, propionic, isobutyric,maleic, malonic, benzoic, succinic, suberic, fumaric, lactic, mandelic,phthalic, benzenesulfonic, p-tolylsulfonic, citric, tartaric,methanesulfonic, and the like. Also included are salts of amino acidssuch as arginate and the like, and salts of organic acids likeglucuronic or galactunoric acids and the like (see, for example, Bergeet al., “Pharmaceutical Salts”, Journal of Pharmaceutical Science, 1977,66, 1-19). Certain specific compounds of the present invention containboth basic and acidic functionalities that allow the compounds to beconverted into either base or acid addition salts.

The neutral forms of the compounds are preferably regenerated bycontacting the salt with a base or acid and isolating the parentcompound in the conventional manner. The parent form of the compounddiffers from the various salt forms in certain physical properties, suchas solubility in polar solvents.

Certain compounds of the present invention can exist in unsolvated formsas well as solvated forms, including hydrated forms. In general, thesolvated forms are equivalent to unsolvated forms and are encompassedwithin the scope of the present invention. Certain compounds of thepresent invention may exist in multiple crystalline or amorphous forms.In general, all physical forms are equivalent for the uses contemplatedby the present invention and are intended to be within the scope of thepresent invention.

Certain compounds of the present invention possess asymmetric carbonatoms (optical centers) or double bonds; the enantiomers, racemates,diastereomers, tautomers, geometric isomers, stereoisometric forms thatmay be defined, in terms of absolute stereochemistry, as (R)- or (S)-or, as (D)- or (L)- for amino acids, and individual isomers areencompassed within the scope of the present invention. The compounds ofthe present invention do not include those which are known in art to betoo unstable to synthesize and/or isolate. The present invention ismeant to include compounds in racemic and optically pure forms.Optically active (R)- and (S)-, or (D)- and (L)-isomers may be preparedusing chiral synthons or chiral reagents, or resolved using conventionaltechniques.

Isomers include compounds having the same number and kind of atoms, andhence the same molecular weight, but differing in respect to thestructural arrangement or configuration of the atoms.

It will be apparent to one skilled in the art that certain compounds ofthis invention may exist in tautomeric forms, all such tautomeric formsof the compounds being within the scope of the invention. Tautomerrefers to one of two or more structural isomers which exist inequilibrium and which are readily converted from one isomeric form toanother.

Unless otherwise stated, structures depicted herein are also meant toinclude all stereochemical forms of the structure; i.e., the R and Sconfigurations for each asymmetric center. Therefore, singlestereochemical isomers as well as enantiomeric and diastereomericmixtures of the present compounds are within the scope of the invention.

Unless otherwise stated, the compounds of the present invention may alsocontain unnatural proportions of atomic isotopes at one or more of theatoms that constitute such compounds. For example, the compounds of thepresent invention may be radiolabeled with radioactive isotopes, such asfor example deuterium (²H), tritium (³H), iodine-125 (¹²⁵I), carbon-13(¹³C), or carbon-14 (¹⁴C). All isotopic variations of the compounds ofthe present invention, whether radioactive or not, are encompassedwithin the scope of the present invention.

In addition to salt forms, the present invention provides compounds,which are in a prodrug form. Prodrugs of the compounds described hereinare those compounds that readily undergo chemical changes underphysiological conditions to provide the compounds of the presentinvention. Additionally, prodrugs can be converted to the compounds ofthe present invention by chemical or biochemical methods in an ex vivoenvironment. For example, prodrugs can be slowly converted to thecompounds of the present invention when placed in a transdermal patchreservoir with a suitable enzyme or chemical reagent.

The compounds of the present invention can be prepared by a variety ofmethods known in the art. See, for example, U.S. Pat. No. 8,685,973,herein incorporated by reference in its entirety.

V. Pharmaceutical Compositions

In some embodiments, the present invention provides a pharmaceuticalcomposition including a pharmaceutically acceptable excipient and thecompound of the present invention.

The compounds of the present invention can be prepared and administeredin a wide variety of oral, parenteral and topical dosage forms. Oralpreparations include tablets, pills, powder, dragees, capsules, liquids,lozenges, gels, syrups, slurries, suspensions, etc., suitable foringestion by the patient. The compounds of the present invention canalso be administered by injection, that is, intravenously,intramuscularly, intracutaneously, subcutaneously, intraduodenally, orintraperitoneally. Also, the compounds described herein can beadministered by inhalation, for example, intranasally. Additionally, thecompounds of the present invention can be administered transdermally.The GR modulators of this invention can also be administered by inintraocular, intravaginal, and intrarectal routes includingsuppositories, insufflation, powders and aerosol formulations (forexamples of steroid inhalants, see Rohatagi, J. Clin. Pharmacol.35:1187-1193, 1995; Tjwa, Ann. Allergy Asthma Immunol. 75:107-111,1995). Accordingly, the present invention also provides pharmaceuticalcompositions including a pharmaceutically acceptable carrier orexcipient and either a compound of Formula (I), or a pharmaceuticallyacceptable salt of a compound of Formula (I).

For preparing pharmaceutical compositions from the compounds of thepresent invention, pharmaceutically acceptable carriers can be eithersolid or liquid. Solid form preparations include powders, tablets,pills, capsules, cachets, suppositories, and dispersible granules. Asolid carrier can be one or more substances, which may also act asdiluents, flavoring agents, binders, preservatives, tabletdisintegrating agents, or an encapsulating material. Details ontechniques for formulation and administration are well described in thescientific and patent literature, see, e.g., the latest edition ofRemington's Pharmaceutical Sciences, Maack Publishing Co, Easton Pa.(“Remington's”).

In powders, the carrier is a finely divided solid, which is in a mixturewith the finely divided active component. In tablets, the activecomponent is mixed with the carrier having the necessary bindingproperties in suitable proportions and compacted in the shape and sizedesired.

The powders and tablets preferably contain from 5% or 10% to 70% of theactive compound. Suitable carriers are magnesium carbonate, magnesiumstearate, talc, sugar, lactose, pectin, dextrin, starch, gelatin,tragacanth, methylcellulose, sodium carboxymethylcellulose, a lowmelting wax, cocoa butter, and the like. The term “preparation” isintended to include the formulation of the active compound withencapsulating material as a carrier providing a capsule in which theactive component with or without other carriers, is surrounded by acarrier, which is thus in association with it. Similarly, cachets andlozenges are included. Tablets, powders, capsules, pills, cachets, andlozenges can be used as solid dosage forms suitable for oraladministration.

Suitable solid excipients are carbohydrate or protein fillers include,but are not limited to sugars, including lactose, sucrose, mannitol, orsorbitol; starch from corn, wheat, rice, potato, or other plants;cellulose such as methyl cellulose, hydroxypropylmethyl-cellulose, orsodium carboxymethylcellulose; and gums including arabic and tragacanth;as well as proteins such as gelatin and collagen. If desired,disintegrating or solubilizing agents may be added, such as thecross-linked polyvinyl pyrrolidone, agar, alginic acid, or a saltthereof, such as sodium alginate.

Dragee cores are provided with suitable coatings such as concentratedsugar solutions, which may also contain gum arabic, talc,polyvinylpyrrolidone, carbopol gel, polyethylene glycol, and/or titaniumdioxide, lacquer solutions, and suitable organic solvents or solventmixtures. Dyestuffs or pigments may be added to the tablets or drageecoatings for product identification or to characterize the quantity ofactive compound (i.e., dosage). Pharmaceutical preparations of theinvention can also be used orally using, for example, push-fit capsulesmade of gelatin, as well as soft, sealed capsules made of gelatin and acoating such as glycerol or sorbitol. Push-fit capsules can contain GRmodulator mixed with a filler or binders such as lactose or starches,lubricants such as talc or magnesium stearate, and, optionally,stabilizers. In soft capsules, the GR modulator compounds may bedissolved or suspended in suitable liquids, such as fatty oils, liquidparaffin, or liquid polyethylene glycol with or without stabilizers.

For preparing suppositories, a low melting wax, such as a mixture offatty acid glycerides or cocoa butter, is first melted and the activecomponent is dispersed homogeneously therein, as by stirring. The moltenhomogeneous mixture is then poured into convenient sized molds, allowedto cool, and thereby to solidify.

Liquid form preparations include solutions, suspensions, and emulsions,for example, water or water/propylene glycol solutions. For parenteralinjection, liquid preparations can be formulated in solution in aqueouspolyethylene glycol solution.

Aqueous solutions suitable for oral use can be prepared by dissolvingthe active component in water and adding suitable colorants, flavors,stabilizers, and thickening agents as desired. Aqueous suspensionssuitable for oral use can be made by dispersing the finely dividedactive component in water with viscous material, such as natural orsynthetic gums, resins, methylcellulose, sodium carboxymethylcellulose,hydroxypropylmethylcellulose, sodium alginate, polyvinylpyrrolidone, gumtragacanth and gum acacia, and dispersing or wetting agents such as anaturally occurring phosphatide (e.g., lecithin), a condensation productof an alkylene oxide with a fatty acid (e.g., polyoxyethylene stearate),a condensation product of ethylene oxide with a long chain aliphaticalcohol (e.g., heptadecaethylene oxycetanol), a condensation product ofethylene oxide with a partial ester derived from a fatty acid and ahexitol (e.g., polyoxyethylene sorbitol mono-oleate), or a condensationproduct of ethylene oxide with a partial ester derived from fatty acidand a hexitol anhydride (e.g., polyoxyethylene sorbitan mono-oleate).The aqueous suspension can also contain one or more preservatives suchas ethyl or n-propyl p-hydroxybenzoate, one or more coloring agents, oneor more flavoring agents and one or more sweetening agents, such assucrose, aspartame or saccharin. Formulations can be adjusted forosmolarity.

Also included are solid form preparations, which are intended to beconverted, shortly before use, to liquid form preparations for oraladministration. Such liquid forms include solutions, suspensions, andemulsions. These preparations may contain, in addition to the activecomponent, colorants, flavors, stabilizers, buffers, artificial andnatural sweeteners, dispersants, thickeners, solubilizing agents, andthe like.

Oil suspensions can be formulated by suspending a compound of thepresent invention in a vegetable oil, such as arachis oil, olive oil,sesame oil or coconut oil, or in a mineral oil such as liquid paraffin;or a mixture of these. The oil suspensions can contain a thickeningagent, such as beeswax, hard paraffin or cetyl alcohol. Sweeteningagents can be added to provide a palatable oral preparation, such asglycerol, sorbitol or sucrose. These formulations can be preserved bythe addition of an antioxidant such as ascorbic acid. As an example ofan injectable oil vehicle, see Minto, J. Pharmacol. Exp. Ther.281:93-102, 1997. The pharmaceutical formulations of the invention canalso be in the form of oil-in-water emulsions. The oily phase can be avegetable oil or a mineral oil, described above, or a mixture of these.Suitable emulsifying agents include naturally-occurring gums, such asgum acacia and gum tragacanth, naturally occurring phosphatides, such assoybean lecithin, esters or partial esters derived from fatty acids andhexitol anhydrides, such as sorbitan mono-oleate, and condensationproducts of these partial esters with ethylene oxide, such aspolyoxyethylene sorbitan mono-oleate. The emulsion can also containsweetening agents and flavoring agents, as in the formulation of syrupsand elixirs. Such formulations can also contain a demulcent, apreservative, or a coloring agent.

The compounds of the invention can be delivered by transdermally, by atopical route, formulated as applicator sticks, solutions, suspensions,emulsions, gels, creams, ointments, pastes, jellies, paints, powders,and aerosols.

The compounds and compositions of the invention can also be delivered asmicrospheres for slow release in the body. For example, microspheres canbe administered via intradermal injection of drug-containingmicrospheres, which slowly release subcutaneously (see Rao, J. BiomaterSci. Polym. Ed. 7:623-645, 1995; as biodegradable and injectable gelformulations (see, e.g., Gao Pharm. Res. 12:857-863, 1995); or, asmicrospheres for oral administration (see, e.g., Eyles, J. Pharm.Pharmacol. 49:669-674, 1997). Both transdermal and intradermal routesafford constant delivery for weeks or months.

The pharmaceutical formulations of the invention can be provided as asalt and can be formed with many acids, including but not limited tohydrochloric, sulfuric, acetic, lactic, tartaric, malic, succinic, etc.Salts tend to be more soluble in aqueous or other protonic solvents thatare the corresponding free base forms. In other cases, the preparationmay be a lyophilized powder in 1 mM-50 mM histidine, 0.1%-2% sucrose,2%-7% mannitol at a pH range of 4.5 to 5.5, that is combined with bufferprior to use

In another embodiment, the formulations of the invention can bedelivered by the use of liposomes which fuse with the cellular membraneor are endocytosed, i.e., by employing ligands attached to the liposome,or attached directly to the oligonucleotide, that bind to surfacemembrane protein receptors of the cell resulting in endocytosis. Byusing liposomes, particularly where the liposome surface carries ligandsspecific for target cells, or are otherwise preferentially directed to aspecific organ, one can focus the delivery of the GR modulator into thetarget cells in vivo. (See, e.g., Al-Muhammed, J. Microencapsul.13:293-306, 1996; Chonn, Curr. Opin. Biotechnol. 6:698-708, 1995; Ostro,Am. J. Hosp. Pharm. 46:1576-1587, 1989).

The pharmaceutical preparation is preferably in unit dosage form. Insuch form the preparation is subdivided into unit doses containingappropriate quantities of the active component. The unit dosage form canbe a packaged preparation, the package containing discrete quantities ofpreparation, such as packeted tablets, capsules, and powders in vials orampoules. Also, the unit dosage form can be a capsule, tablet, cachet,or lozenge itself, or it can be the appropriate number of any of thesein packaged form.

The quantity of active component in a unit dose preparation may bevaried or adjusted from 0.1 mg to 10000 mg, more typically 1.0 mg to1000 mg, most typically 10 mg to 500 mg, according to the particularapplication and the potency of the active component. The compositioncan, if desired, also contain other compatible therapeutic agents.

The dosage regimen also takes into consideration pharmacokineticsparameters well known in the art, i.e., the rate of absorption,bioavailability, metabolism, clearance, and the like (see, e.g.,Hidalgo-Aragones (1996) J. Steroid Biochem. Mol. Biol. 58:611-617;Groning (1996) Pharmazie 51:337-341; Fotherby (1996) Contraception54:59-69; Johnson (1995) J. Pharm. Sci. 84:1144-1146; Rohatagi (1995)Pharmazie 50:610-613; Brophy (1983) Eur. J. Clin. Pharmacol. 24:103-108;the latest Remington's, supra). The state of the art allows theclinician to determine the dosage regimen for each individual patient,GR modulator and disease or condition treated.

Single or multiple administrations of formulations can be administereddepending on the dosage and frequency as required and tolerated by thepatient. The formulations should provide a sufficient quantity of activeagent to effectively treat the disease state. Thus, in one embodiment,the pharmaceutical formulations for oral administration of the compoundof the present invention is in a daily amount of between about 0.5 toabout 20 mg per kilogram of body weight per day. In an alternativeembodiment, dosages are from about 1 mg to about 4 mg per kg of bodyweight per patient per day are used. Lower dosages can be used,particularly when the drug is administered to an anatomically secludedsite, such as the cerebral spinal fluid (CSF) space, in contrast toadministration orally, into the blood stream, into a body cavity or intoa lumen of an organ. Substantially higher dosages can be used in topicaladministration. Actual methods for preparing parenterally administrableformulations will be known or apparent to those skilled in the art andare described in more detail in such publications as Remington's, supra.See also Nieman, In “Receptor Mediated Antisteroid Action,” Agarwal, etal., eds., De Gruyter, N.Y. (1987).

The compounds described herein can be used in combination with oneanother, with other active agents known to be useful in modulating aglucocorticoid receptor, or with adjunctive agents that may not beeffective alone, but may contribute to the efficacy of the active agent.

In some embodiments, co-administration includes administering one activeagent within 0.5, 1, 2, 4, 6, 8, 10, 12, 16, 20, or 24 hours of a secondactive agent. Co-administration includes administering two active agentssimultaneously, approximately simultaneously (e.g., within about 1, 5,10, 15, 20, or 30 minutes of each other), or sequentially in any order.In some embodiments, co-administration can be accomplished byco-formulation, i.e., preparing a single pharmaceutical compositionincluding both active agents. In other embodiments, the active agentscan be formulated separately. In another embodiment, the active and/oradjunctive agents may be linked or conjugated to one another.

After a pharmaceutical composition including a GR modulator of theinvention has been formulated in an acceptable carrier, it can be placedin an appropriate container and labeled for treatment of an indicatedcondition. For administration of compounds of the present invention,such labeling would include, e.g., instructions concerning the amount,frequency and method of administration.

The pharmaceutical compositions of the present invention can be providedas a salt and can be formed with many acids, including but not limitedto hydrochloric, sulfuric, acetic, lactic, tartaric, malic, succinic,etc. Salts tend to be more soluble in aqueous or other protonic solventsthat are the corresponding free base forms. In other cases, thepreparation may be a lyophilized powder in 1 mM-50 mM histidine, 0.1%-2%sucrose, 2%-7% mannitol at a pH range of 4.5 to 5.5, that is combinedwith buffer prior to use.

In another embodiment, the compositions of the present invention areuseful for parenteral administration, such as intravenous (IV)administration or administration into a body cavity or lumen of anorgan. The formulations for administration will commonly comprise asolution of the compositions of the present invention dissolved in apharmaceutically acceptable carrier. Among the acceptable vehicles andsolvents that can be employed are water and Ringer's solution, anisotonic sodium chloride. In addition, sterile fixed oils canconventionally be employed as a solvent or suspending medium. For thispurpose any bland fixed oil can be employed including synthetic mono- ordiglycerides. In addition, fatty acids such as oleic acid can likewisebe used in the preparation of injectables. These solutions are sterileand generally free of undesirable matter. These formulations may besterilized by conventional, well known sterilization techniques. Theformulations may contain pharmaceutically acceptable auxiliarysubstances as required to approximate physiological conditions such aspH adjusting and buffering agents, toxicity adjusting agents, e.g.,sodium acetate, sodium chloride, potassium chloride, calcium chloride,sodium lactate and the like. The concentration of the compositions ofthe present invention in these formulations can vary widely, and will beselected primarily based on fluid volumes, viscosities, body weight, andthe like, in accordance with the particular mode of administrationselected and the patient's needs. For IV administration, the formulationcan be a sterile injectable preparation, such as a sterile injectableaqueous or oleaginous suspension. This suspension can be formulatedaccording to the known art using those suitable dispersing or wettingagents and suspending agents. The sterile injectable preparation canalso be a sterile injectable solution or suspension in a nontoxicparenterally-acceptable diluent or solvent, such as a solution of1,3-butanediol.

VI. Method of Treating Fatty Liver Disease

In some embodiments, the present invention provides a method of treatinga disorder or condition through modulating a glucocorticoid receptor,the method including administering to a subject in need of suchtreatment, a therapeutically effective amount of a compound of formulaI.

In some other embodiments, the present invention provides a method oftreating a disorder or condition through antagonizing a glucocorticoidreceptor, the method including administering to a subject in need ofsuch treatment, an effective amount of the compound of formula I.

In another embodiment, the present invention provides methods ofmodulating nuclear receptor activity using the techniques describedherein. In an exemplary embodiment, the method includes contacting a GRand a MR with an effective amount of a compound of the presentinvention, such as the compound of formula I, and detecting a change inGR and MR activity.

In an exemplary embodiment, the nuclear modulator is an antagonist of GRand MR activity. A nuclear receptor antagonist, as used herein, refersto any composition or compound which partially or completely inhibits(antagonizes) the binding of a glucocorticoid receptor (GR) agonist(e.g. cortisol and synthetic or natural cortisol analog) to a GR, andpartially or completely inhibits (antagonizes) the binding of amineralocorticoid receptor (MR) agonist (e.g. aldosterone and syntheticor natural aldosterone analog) to a MR, thereby inhibiting anybiological response associated with the binding of a GR and a MR to theagonist. In some embodiments, the nuclear receptor antagonistpreferentially binds to the GR and/or MR over the estrogen receptor(ER), progesterone receptor (PR) and/or the androgen receptor (AR). Thepreference of the nuclear receptor antagonist for GR and/or MR over theER, PR and/or AR can be greater than at least 10:1. For example, thepreference can be at least 10:1, 50:1, 100:1, 500:1 or at least 1000:1.In some embodiments, the nuclear receptor antagonist preferentiallybinds to the GR and/or MR over the ER, PR and/or AR by at least 100:1.

In some embodiments, the nuclear receptor antagonist of the presentinvention can be used in combination with one or more treatments toameliorate or reduce one or more symptoms of fatty liver disease. Thenuclear antagonist can be administered to a patient with fatty liverdisease who is undergoing or has undergone lifestyle modifications, suchas, adoption of a weight loss regimen or caloric restriction, increasedexercise, and/or avoidance of alcohol or heptatoxins. The patient mayundergo or have undergone weight-reduction surgery (bariatric surgery).In some embodiments, the specific glucocorticoid receptor antagonist isadministered to an individual in combination with a therapeutic agent,such as but not limited to, propylthiouracil, infliximab, insulin,glucagon, calcium channel blockers, antioxidants (e.g., vitamin E),S-adenosyl-L-methionine (SAMe), silymarin, and pentoxyfylline to treatalcoholic related fatty liver disease including AFL and ASH. In otherembodiments, the specific glucocorticoid receptor antagonist isadministered to an individual with a therapeutic agent, such as but notlimited to, a serotonin reuptake inhibitor, sibutramine, orlistat,insulin-sensitizing agent (e.g., thiazolidinedione, rosiglitasone andpioglitazone), lipid-lowering agent (e.g., probucol), antioxidants(e.g., vitamin E, pentoxifylline, betaine and N-acetylcysteine),hepatoprotective therapy (e.g., ursodeoxycholic acid),angiotensin-converting enzyme inhibitor, angiotensin-receptor block,metformin, monounsaturated fatty acids, polyunsaturated fatty acids, andcombinations thereof to treat nonalcoholic fatty liver disease includingNASH.

VII. Assays and Methods for Testing Compounds to Treat Fatty LiverDisease

The compounds of the present invention can be tested for theirantiglucocorticoid properties. Methods of assaying compounds capable ofmodulating glucocorticoid receptor activity are presented herein.Typically, compounds of the current invention are capable of modulatingnuclear receptor activity by binding to the nuclera receptors such as GRand MR, or by preventing GR and MR ligands from binding to thecorresponding GR andMR. In some embodiments, the compounds exhibitlittle or no cytotoxic effect.

A. Binding Assays

In some embodiments, nuclear receptor modulators are identified byscreening for molecules that compete with a ligand of the nuclearreceptor, such as dexamethasone. Those of skill in the art willrecognize that there are a number of ways to perform competitive bindingassays. In some embodiments, the nuclear receptor is pre-incubated witha labeled nuclear receptor ligand and then contacted with a testcompound. This type of competitive binding assay may also be referred toherein as a binding displacement assay. Alteration (e.g., a decrease) ofthe quantity of ligand bound to the nuclear receptor indicates that themolecule is a potential nuclear receptor modulator. Alternatively, thebinding of a test compound to the nuclear receptor can be measureddirectly with a labeled test compound. This latter type of assay iscalled a direct binding assay.

Both direct binding assays and competitive binding assays can be used ina variety of different formats. The formats may be similar to those usedin immunoassays and receptor binding assays. For a description ofdifferent formats for binding assays, including competitive bindingassays and direct binding assays, see Basic and Clinical Immunology 7thEdition (D. Stites and A. Terr ed.) 1991; Enzyme Immunoassay, E. T.Maggio, ed., CRC Press, Boca Raton, Fla. (1980); and “Practice andTheory of Enzyme Immunoassays,” P. Tijssen, Laboratory Techniques inBiochemistry and Molecular Biology, Elsevier Science Publishers B.V.Amsterdam (1985), each of which is incorporated herein by reference.

In solid phase competitive binding assays, for example, the samplecompound can compete with a labeled analyte for specific binding siteson a binding agent bound to a solid surface. In this type of format, thelabeled analyte can be a nuclear receptor ligand and the binding agentcan be nuclear receptor bound to a solid phase. Alternatively, thelabeled analyte can be labeled nuclear receptor and the binding agentcan be a solid phase nuclear receptor ligand. The concentration oflabeled analyte bound to the capture agent is inversely proportional tothe ability of a test compound to compete in the binding assay.

Alternatively, the competitive binding assay may be conducted in liquidphase, and any of a variety of techniques known in the art may be usedto separate the bound labeled protein from the unbound labeled protein.For example, several procedures have been developed for distinguishingbetween bound ligand and excess bound ligand or between bound testcompound and the excess unbound test compound. These includeidentification of the bound complex by sedimentation in sucrosegradients, gel electrophoresis, or gel isoelectric focusing;precipitation of the receptor-ligand complex with protamine sulfate oradsorption on hydroxylapatite; and the removal of unbound compounds orligands by adsorption on dextran-coated charcoal (DCC) or binding toimmobilized antibody. Following separation, the amount of bound ligandor test compound is determined.

Alternatively, a homogenous binding assay may be performed in which aseparation step is not needed. For example, a label on the nuclearreceptor may be altered by the binding of the nuclear receptor to itsligand or test compound. This alteration in the labeled nuclear receptorresults in a decrease or increase in the signal emitted by label, sothat measurement of the label at the end of the binding assay allows fordetection or quantitation of the nuclear receptor in the bound state. Awide variety of labels may be used. The component may be labeled by anyone of several methods. Useful radioactive labels include thoseincorporating ³H, ¹²⁵I, ³⁵S, ¹⁴C, or ³²P. Useful non-radioactive labelsinclude those incorporating fluorophores, chemiluminescent agents,phosphorescent agents, electrochemiluminescent agents, and the like.Fluorescent agents are especially useful in analytical techniques thatare used to detect shifts in protein structure such as fluorescenceanisotropy and/or fluorescence polarization. The choice of label dependson sensitivity required, ease of conjugation with the compound,stability requirements, and available instrumentation. For a review ofvarious labeling or signal producing systems which may be used, see U.S.Pat. No. 4,391,904, which is incorporated herein by reference in itsentirety for all purposes. The label may be coupled directly orindirectly to the desired component of the assay according to methodswell known in the art.

High-throughput screening methods may be used to assay a large number ofpotential modulator compounds. Such “compound libraries” are thenscreened in one or more assays, as described herein, to identify thoselibrary members (particular chemical species or subclasses) that displaya desired characteristic activity. Preparation and screening of chemicallibraries is well known to those of skill in the art. Devices for thepreparation of chemical libraries are commercially available (see, e.g.,357 MPS, 390 MPS, Advanced Chem Tech, Louisville Ky., Symphony, Rainin,Woburn, Mass., 433A Applied Biosystems, Foster City, Calif., 9050 Plus,Millipore, Bedford, Mass.).

B. Cell-Based Assays

Cell-based assays involve whole cells or cell fractions containingnuclear receptor to assay for binding or modulation of activity ofnuclear receptor by a compound of the present invention. Exemplary celltypes that can be used according to the methods of the inventioninclude, e.g., any mammalian cells including leukocytes such asneutrophils, monocytes, macrophages, eosinophils, basophils, mast cells,and lymphocytes, such as T cells and B cells, leukemias, Burkitt'slymphomas, tumor cells (including mouse mammary tumor virus cells),endothelial cells, fibroblasts, cardiac cells, muscle cells, breasttumor cells, ovarian cancer carcinomas, cervical carcinomas,glioblastomas, liver cells, kidney cells, and neuronal cells, as well asfungal cells, including yeast. Cells can be primary cells or tumor cellsor other types of immortal cell lines. Of course, nuclear receptor canbe expressed in cells that do not express an endogenous version ofnuclear receptor.

In some cases, fragments of nuclear receptor, as well as proteinfusions, can be used for screening. When molecules that compete forbinding with nuclear receptor ligands are desired, the nuclear receptorfragments used are fragments capable of binding the ligands (e.g.,dexamethasone). Alternatively, any fragment of nuclear receptor can beused as a target to identify molecules that bind nuclear receptor.nuclear receptor fragments can include any fragment of, e.g., at least20, 30, 40, 50 amino acids up to a protein containing all but one aminoacid of nuclear receptor. Typically, ligand-binding fragments willcomprise transmembrane regions and/or most or all of the extracellulardomains of nuclear receptor.

In some embodiments, signaling triggered by nuclear receptor activationis used to identify nuclear receptor modulators. Signaling activity ofnuclear receptor can be determined in many ways. For example, downstreammolecular events can be monitored to determine signaling activity.Downstream events include those activities or manifestations that occuras a result of stimulation of a nuclear receptor receptor. Exemplarydownstream events useful in the functional evaluation of transcriptionalactivation and antagonism in unaltered cells include upregulation of anumber of response element (RE)-dependent genes (PEPCK, tyrosine aminotransferase, aromatase). In addition, specific cell types susceptible tonuclear receptor activation may be used, such as osteocalcin expressionin osteoblasts which is downregulated by glucocorticoids; primaryhepatocytes which exhibit nuclear receptor mediated upregulation ofPEPCK and glucose-6-phospahte (G-6-Pase)). RE-mediated gene expressionhas also been demonstrated in transfected cell lines using well-knownRE-regulated sequences (e.g. the mouse mammary tumor virus promoter(MMTV) transfected upstream of a reporter gene construct). Examples ofuseful reporter gene constructs include luciferase (luc), alkalinephosphatase (ALP) and chloramphenicol acetyl transferase (CAT). Thefunctional evaluation of transcriptional repression can be carried outin cell lines such as monocytes or human skin fibroblasts. Usefulfunctional assays include those that measure IL-1beta stimulated IL-6expression; the downregulation of collagenase, cyclooxygenase-2 andvarious chemokines (MCP-1, RANTES); or expression of genes regulated byNF-κB or AP-1 transcription factors in transfected cell-lines.

Typically, compounds that are tested in whole-cell assays are alsotested in a cytotoxicity assay. Cytotoxicity assays are used todetermine the extent to which a perceived modulating effect is due tonon-nuclear receptor binding cellular effects. In an exemplaryembodiment, the cytotoxicity assay includes contacting a constitutivelyactive cell with the test compound. Any decrease in cellular activityindicates a cytotoxic effect.

C. Specificity

The compounds of the present invention may be subject to a specificityassay (also referred to herein as a selectivity assay). Typically,specificity assays include testing a compound that binds nuclearreceptor in vitro or in a cell-based assay for the degree of binding tonon-nuclear receptor proteins. Selectivity assays may be performed invitro or in cell based systems, as described above. Nuclear receptorbinding may be tested against any appropriate non-nuclear receptorprotein, including antibodies, receptors, enzymes, and the like. In anexemplary embodiment, the non-nuclear receptor binding protein is acell-surface receptor or nuclear receptor. In another exemplaryembodiment, the non-nuclear receptor protein is a steroid receptor, suchas estrogen receptor, progesterone receptor, or androgen receptor.

The terms and expressions which have been employed herein are used asterms of description and not of limitation, and there is no intention inthe use of such terms and expressions of excluding equivalents of thefeatures shown and described, or portions thereof, it being recognizedthat various modifications are possible within the scope of theinvention claimed. Moreover, any one or more features of any embodimentof the invention may be combined with any one or more other features ofany other embodiment of the invention, without departing from the scopeof the invention. For example, the features of the nuclear receptormodulator compounds are equally applicable to the methods of treatingdisease states and/or the pharmaceutical compositions described herein.All publications, patents, and patent applications cited herein arehereby incorporated by reference in their entirety for all purposes.

VIII. EXAMPLES Example 1. GR Reporter Gene Assay Using SW1353/MMTV-5Cells

SW1353/M MTV-5 is an adherent human chondrosarcoma cell line thatcontains endogenous glucocorticoid receptors. It was transfected with aplasmid (pMAMneo-Luc) encoding firefly luciferase located behind aglucocorticoid-responsive element (GRE) derived from a viral promoter(long terminal repeat of mouse mammary tumor virus). A stable cell lineSW1353/MMTV-5 was selected with geneticin, which was required tomaintain this plasmid. This cell line was thus sensitive toglucocorticoids (dexamethasone) leading to expression of luciferase(EC₅₀ ^(dex) 10 nM). This dexamethasone-induced response was graduallylost over time, and a new culture from an earlier passage was started(from a cryo-stored aliquot) every three months.

In order to test for a GR-antagonist, such as Compound 1, SW1353/MMTV-5cells were incubated with several dilutions of the compounds in thepresence of 5xEC₅₀ ^(dex) (50 nM), and the inhibition of inducedluciferase expression was measured using luminescence detected on aTopcount (Britelite Plus kit, Perking Elmer). For each assay, adose-response curve for dexamethasone was prepared in order to determinethe EC₅₀ ^(dex) required for calculating the K_(i) from the IC₅₀ of thetest compound, e.g., Compound 1.

SW1353/MMTV-5 cells were distributed in 96-well plates and incubated inmedium (without geneticin) for 24 hrs. Dilutions of the test compound inmedium+50 nM dexamethasone were added and the plates further incubatedfor another 24 hours after which the luciferase expression is measured.

Compound 1 is named(E)-6-(4-phenylcyclohexyl)-5-(3-trifluoromethylbenzyl)-1H-pyrimidine-2,4-dioneor6-((1r,4r)-4-phenylcyclohexyl)-5-(3-(trifluoromethyl)benzyl)pyrimidine-2,4(1H,3H)-dione,and has the chemical structure shown below.

Compound 1 is an antagonist of the glucocorticoid receptor (GRII). Inreporter gene assays, Compound 1 has a K_(i) of 24 nM for GR.

Example 2. MR and PR Reporter Gene Assays Using T47D/MMTV-5 Cells

T47D/MMTV-5 is an adherent human breast carcinoma cell line containingendogenous mineralocorticoid and progesterone receptors (PR). Asdescribed for the SW1353 cell line above, T47D cells were transfectedwith the same pMAMneo-Luc plasmid, and stable lines were selected withgeneticin. A cell line T47D/MMTV-5 was isolated, which responded toaldosterone (EC₅₀ 100 nM) and progesterone (EC₅₀ 10 nM), leading toexpression of luciferase. To test for MR or PR antagonists, theT47D/MMTV-5 cells were incubated with several dilutions of the compoundsin the presence of 5 times the EC₅₀ of the agonist aldosterone orprogesterone. For each assay, a dose response curve was prepared forboth aldostreone and progesterone.

T47D/MMTV-5 calls were distributed in 96-well plates (100 μl) in RPMI640medium+10% charcoal stripped FCS. The cells were incubated for 24 hoursin a CO₂ oven. A volume of 100 μl of the compound dilutions inmedium+agonist (500 nM aldosterone, 50 nM progesterone) were added, andthe plates were incubated for another 24 hours, after which luciferaseexpression was measured.

Compound 1 is an antagonist of the mineralocorticoid receptor (MR, GRI).In reporter gene assays, Compound 1 has a K_(i) of 148 nM for MR.Compound 1 is inactive in a progesterone receptor reporter gene assay.

Example 3. Determination of Liver Lipids in Mice Fed a High Fat Diet

C57B16/J mice (n=8 per group) were given a high fat diet (60% fat) forthree weeks and then sacrificed. Livers were collected and weighed.Liver slices were prepared and analysed for lipid levels by Oil Red Ostaining (FIGS. 1 and 3). One group of mice received Compound 1 mixed inthe food (60 mg/kg/day) whilst another group of mice received vehiclemixed in the food. The livers of Compound 1 fed mice had no or low levelof lipid droplets (FIG. 2A), while the control mice had more lipiddroplets (FIG. 2B). An additional group received mifepristone (RU-486;60 mg/kg/day) in the food. Compound 1 has GR antagonist activity andsome MR antagonist activity. The data shows that mifepristone causedincreased fatty liver compared to the controls. Compound 1 had anopposite effect and did not induce fatty liver.

In a separate experiment (FIG. 4), the accumulation of fat in the liversof mice fed a high fat diet (60% fat) and then sacrificed was determinedby homogenizing the livers and extracting triglycerides. This experimentincluded 5 groups of mice:

Group 1 (“CHOW”): normal diet for 6 weeks;

Group 2 (“HF-3wks”): high fat diet for 3 weeks;

Group 3 (“HF-6wks”): high fat diet for 6 weeks;

Group 4 (“HF+118335-6wks”): high fat diet and Compound 1 for 6 weeks;

Group 5 (“HF-118335 rev”): high fat diet for 3 weeks followed by highfat diet and Compound 1 for 3 weeks.

Example 4. GR Protein:Protein Interaction Assay

Protein:protein interaction assays were used to determine the ability oftest compounds to act as antagonists of the glucocorticoid receptorand/or mineralocorticoid receptor. These assays utilize a commercialassay platform provided by DiscoveRx Corp. (Fremont, Calif.). DiscoveRxtechnology is based on β-galactosidase enzyme fragment complementationusing a luminogenic substrate. Briefly, Chinese hamster ovary cells(CHO-K1) have been engineered to express either human recombinant GR orMR together with a steroid responsive coactivator protein (SRCP) calledPGC1α (peroxisome proliferator activated receptor gamma coactivator 1α).The assay measures the net outcome of GR or MR activation, i.e., nucleartranslocation from the cytoplasm and interaction of the GR or MR withthe coactivator PGC1α in the cell nucleus. The assay can be configuredin both agonist and antagonist modes.

The cells (100 μl) were plated into 96 well plates and placed in a 37°C., 5% CO₂ incubator for 24 hours. After removing the cells from theincubator, 5 μl of test compound or vehicle was added to each well, andthe plates were incubated for 1 hour at 37° C., 5% CO₂. Dexamethasone (5μl of 792 nM solution) or vehicle was added to each well of the plates,and the plates were incubated for 6 hours at 37° C., 5% CO₂. Thedetection reagent was added, 55 μl per well, and the plates wereincubated at room temperature in the dark without mixing. The plateswere read for luminescence using an EnVision® plate reader (3 hourread). Luminescence values were expressed as a percent inhibition (%inhibition) of 36 nM dexamethasone, and K_(i) values were calculatedfrom the experimentally determined IC₅₀ values using the Cheng-Prusoffequation. It was determined that Compound 1 has a K_(i) of 118 nM inthis assay.

Example 5. MR Protein:Protein Interaction Assay

The cells (100 μl) were plated into 96 well plates and placed in a 37°C., 5% CO₂ incubator for 24 hours. After removing the cells from theincubator, 5 μl of test compound or vehicle was added to each well, andthe plates were incubated for 1 hour at 37° C., 5% CO₂. Aldosterone (5μl of 88 nM solution) or vehicle was added to each well of the plates,and the plates were incubated for 6 hours at 37° C., 5% CO₂. Thedetection reagent was added, 55 μl per well, and the plates wereincubated at room temperature in the dark without mixing. The plateswere read for luminescence using an EnVision® (Perkin Elmer, Walthan,Mass.) plate reader (3 hour read). Luminescence values were expressed asa percent inhibition (% inhibition) of 4 nM aldosterone, and K_(i)values were calculated from the experimentally determined IC₅₀ valuesusing the Cheng-Prusoff equation. It was determined that Compound 1 hasa K_(i) of 125 nM in this assay.

Although the foregoing invention has been described in some detail byway of illustration and example for purposes of clarity ofunderstanding, one of skill in the art will appreciate that certainchanges and modifications may be practiced within the scope of theappended claims. In addition, each reference provided herein isincorporated by reference in its entirety to the same extent as if eachreference was individually incorporated by reference. Where a conflictexists between the instant application and a reference provided herein,the instant application shall dominate.

What is claimed is:
 1. A method of treating fatty liver disease,comprising administering to a subject in need thereof, a therapeuticallyeffective amount of a compound of Formula Id and a further treatment forsaid fatty liver disease, thereby treating the fatty liver disease,wherein the compound of Formula Id has the structure:

wherein each R^(1a) is independently H, C₁₋₆ alkyl, halogen, or C₁₋₆haloalkyl; R² is H, or C₁₋₆ alkyl; and each R⁴ is H, C₁₋₆ alkyl,halogen, or C₁₋₆ haloalkyl; or salts or isomers thereof.
 2. The methodof claim 1, wherein the fatty liver disease is nonalcoholic fatty liverdisease (NAFLD).
 3. The method of claim 1, wherein the fatty liverdisease is an alcohol related liver disease selected from alcohol fattyliver disease (AFL), alcoholic steatohepatitis (ASH) and alcoholiccirrhosis.
 4. The method of claim 2, wherein the nonalcoholic fattyliver disease is nonalcoholic steatohepatitis (NASH) or nonalcoholiccirrhosis.
 5. The method of claim 1, wherein each R^(1a) is C₁₋₆haloalkyl.
 6. The method of claim 1, wherein each R^(1a) isindependently selected from the group consisting of H, Me, Et, F, Cl, or—CF₃.
 7. The method of claim 1, wherein each R^(1a) is —CF₃.
 8. Themethod of claim 1, wherein R² is H.
 9. The method of claim 1, whereinthe compound of Formula Id is selected from the group consisting of:


10. The method of claim 1, the compound of Formula Id having theformula:


11. The method of claim 1, wherein said compound of Formula Id is anantagonist of the glucocorticoid receptor.
 12. The method of claim 1,wherein said compound of Formula Id is an antagonist of themineralocorticoid receptor.
 13. The method of claim 1, wherein saidcompound of Formula Id inhibits glucocorticoid binding to theglucocorticoid receptor and is an antagonist of the mineralocorticoidreceptor.
 14. The method of claim 1, wherein said compound of Formula Idinhibits glucocorticoid binding to the glucocorticoid receptor with aninhibition constant (K_(i)) of between about 0.0001 nanomolar (nM) to1000 nM and is an antagonist of the mineralocorticoid receptor.
 15. Themethod of claim 1, wherein said further treatment comprises a lifestylemodification.
 16. The method of claim 15, wherein said lifestylemodification is selected from the group of lifestyle modificationsconsisting of adoption of a weight loss regimen, caloric restriction,increased exercise, avoidance of alcohol, and avoidance of heptatoxins.17. The method of claim 1, wherein said further treatment comprisesweight reduction surgery.
 18. The method of claim 1, wherein saidfurther treatment comprises administration of a therapeutic agentselected from the group consisting of propylthiouracil, infliximab,insulin, glucagon, a calcium channel blocker, an antioxidant,S-adenosyl-L-methionine (SAMe), silymarin, and pentoxyfylline.
 19. Themethod of claim 18, wherein said fatty liver disease is analcoholic-related fatty liver disease.
 20. The method of claim 1,wherein said further treatment comprises administration of a therapeuticagent selected from the group consisting of a serotonin reuptakeinhibitor, sibutramine, orlistat, an insulin-sensitizing agent, alipid-lowering agent, an antioxidant, a hepatoprotective therapeuticagent, an angiotensin-converting enzyme inhibitor, anangiotensin-receptor blocker, metformin, a monounsaturated fatty acid, apolyunsaturated fatty acid, and combinations thereof.
 21. The method ofclaim 20, wherein said insulin-sensitizing agent is selected from thegroup consisting of thiazolidinedione, rosiglitazone, and pioglitazone;said lipid-lowering agent is probucol; said antioxidant is selected fromthe group consisting of vitamin E, pentoxifylline, betaine andN-acetylcysteine; and said hepatoprotective therapeutic agent isursodeoxycholic acid.
 22. The method of claim 20, wherein said fattyliver disease is a nonalcoholic fatty liver disease.
 23. The method ofclaim 21, wherein said fatty liver disease is a nonalcoholic fatty liverdisease.